J. Perinat. Med.
2023; 51(2): 240–252
Asim Kurjak, Edin Medjedovic* and Milan Stanojevic
Use and misuse of ultrasound in obstetrics with
reference to developing countries
https://doi.org/10.1515/jpm-2022-0438
Received September 7, 2022; accepted October 4, 2022;
published online October 28, 2022
Abstract: Maternal and neonatal health is one of the main
global health challenges. Every day, approximately 800
women and 7,000 newborns die due to complications
during pregnancy, delivery, and neonatal period. The
leading causes of maternal death in sub-Saharan Africa are
obstetric hemorrhage (28.8%), hypertensive disorders in
pregnancy (22.1%), non-obstetric complications (18.8%),
and pregnancy-related infections (11.5%). Diagnostic ul-
trasound examinations can be used in a variety of specific
circumstances during pregnancy. Because adverse out-
comes may also arise in low-risk pregnancies, it is assumed
that routine ultrasound in all pregnancies will enable
earlier detection and improved management of pregnancy
complications. The World Health Organization (WHO)
estimated in 1997 that 50% of developing countries had no
access to ultrasound imaging, and available equipment
was outdated or broken. Unfortunately, besides all the
exceptional benefits of ultrasound in obstetrics, its inap-
propriate use and abuse are reported. Using ultrasound to
view, take a picture, or determine the sex of a fetus without
a medical indication can be considered ethically unjusti-
fiable. Ultrasound assessment when indicated should be
every woman’s right in the new era. However, it is still only
a privilege in some parts of the world. Investment in both
equipment and human resources has been clearly shown
to be cost-effective and should be an obligatory step in
the improvement of health care. Well-developed health
*Corresponding author: Edin Medjedovic, MD, PhD, Clinic of
Gynecology and Obstetrics, Clinical Center University of Sarajevo,
Sarajevo, Bosnia and Herzegovina; and Department of Gynecology,
School of Medicine, Sarajevo School of Science and Technology,
Sarajevo, Bosnia and Herzegovina, E-mail: medjedovic.e@gmail.com.
https://orcid.org/0000-0003-2357-9580
Asim Kurjak, Department of Obstetrics and Gynecology, University
Hospital “Sveti Duh”, Zagreb, Croatia
Milan Stanojevic, Department of Obstetrics and Gynecology,
University Hospital “Sveti Duh”, Zagreb, Croatia; and Neonatal Unit,
Department of Obstetrics and Gynecology, Medical School University
of Zagreb, Zagreb, Croatia
systems should guide developing countries, creating
principles for the organization of the health system with an
accent on the correct, legal, and ethical use of diagnostic
ultrasound in pregnancy to avoid its misuse. The aim of
the article is to present the importance of correct and
appropriate use of ultrasound in obstetrics and gynecology
with reference to developing countries.
Keywords: gynecology; maternal health; obstetrics.
Introduction
The history of sonography in obstetrics and gynaecology
started with the classic 1958 Lancet paper of Ian Donald
and his team from Glasgow [1]. Today, practicing obstetrics
and gynecology without ultrasound is unimaginable.
Ultrasound is convenient examination and safe even for
the embryo [2]. However, the usefulness of ultrasound
depends heavily on the operator’s skill. Real-time imaging,
color and power Doppler, transvaginal sonography, and
3/4D imaging have been used for the assessment of fetal
growth and wellbeing, screening for fetal anomalies, pre-
diction of preeclampsia and preterm birth, and detection of
ectopic gestation, evaluation of pelvic masses, screening
for ovarian cancer and fertility management [1]. Ultrasound
poses a significant role in reducing mortality and morbidity
in mothers and their babies [3]. The aim of the article is to
present the importance of correct and appropriate use of
ultrasound in obstetrics and gynecology with reference to
developing countries.
Maternal and neonatal mortality
and morbidity
Lee Jong-wook, former director of the World Health
Organization (WHO), once said: “Even in the 21st century,
we still allow well over 10 million children and half a
million mothers to die each year, although most of these
deaths can be avoided [4].”
Maternal and neonatal health is one of the main global
health challenges. Every day, approximately 800 women

and 7,000 newborns die due to complications during
pregnancy, delivery, and neonatal period [5]. It is esti-
mated that 94% of all maternal deaths occur in low and
lower-middle-income countries [6].
In 2017, 295,000 maternal deaths occurred and the
global maternal mortality rate (MMR) was 211 maternal
deaths per 100,000 live births [7]. Sub-Saharan Africa
alone accounted for 66%, and Southern Asia for 20% of
global maternal deaths [7]. With approximately 67,000 and
35,000 maternal deaths, Nigeria and India accounted for
23 and 12% of global maternal deaths, respectively [7].
The lifetime risk of maternal death in sub-Saharan Africa
is 1 in 37, while in Australia and New Zealand is just 1 in
7,800 [7]. MMR in the world’s least developed countries
(415 per 100,000 live births) is more than 40 times higher
than MMR in Europe [10], and almost 60 times higher than
in Australia and New Zealand [7]. South Sudan, Chad, and
Sierra Leone are estimated to have had extremely high
MMR in 2017 (over 1,000 maternal deaths per 100,000 live
births) [7].
Almost 75% of all maternal deaths are caused by
severe bleeding, infections, high blood pressure during
pregnancy, complications from delivery, and unsafe
abortion [6]. The leading causes of maternal death in
sub-Saharan Africa are obstetric hemorrhage (28.8%),
hypertensive disorders in pregnancy (22.1%), non-obstetric
complications (18.8%), and pregnancy-related infections
(11.5%) [8].
The estimated number of neonatal deaths was 2.5
million deaths in 2017 [9].Together, South Asia and sub-
Saharan Africa accounted for 79% of the total neonatal
deaths [9].Neonatal mortality rate (NMR, number of
neonatal deaths per 1,000 live births) was more than 9
times higher in west and central Africa (30.2 per 1,000 live
births) and south Asia (26.9 per 1,000 live births) than in
high-income countries (3.0 per 1,000 live births) [9].
Leading causes of neonatal deaths in 2017 were: compli-
cations associated with preterm birth (35%), birth asphyxia
(24%), sepsis and meningitis (14%), and congenital
anomalies (11%) [9]. In sub-Saharan Africa, leading causes
of nonatal deaths are infections such as tetanus, sepsis and
pneumonia, preterm birth complications, and birth
asphyxia [10]. In a study conducted in western Ethiopia,
60% of neonatal deaths in the period 2010–2014 were due
to infection [11].
It is clearly shown that maternal and neonatal mortality
result from preventable causes [12]. It is estimated that 71%
of neonatal and 51% of maternal deaths annually can be
prevented through increased coverage of preconception,
Kurjak et al.: Use and misuse of ultrasound in obstetrics 241
prenatal, intrapartum, and postnatal care [13]. Almost 3
million lives could be saved each year by high coverage of
care around the time of birth, and care of small and sick
newborns, at an additional cost of just 1.15 US$ per person
[5]. In low-income countries, about 50% of mothers have no
access to skilled attendants at birth, and over 70% of extra
hospital deliveries do not receive postnatal care [13]. Studies
conducted in Ethiopia, sub-Saharan Africa, and Iran
showed that good prenatal care and skilled personnel at
birth decrease the odds of neonatal death [14–16]. Even one
antenatal care visit in pregnancy, by a skilled provider, re-
duces the risk of neonatal mortality by 39% in sub-Saharan
African countries [10].
The ultrasound is proven to be reducing maternal and
neonatal mortality and morbidity [17]. It is considered a
type of sustainable technology for developing countries
due to the relatively low cost of purchase, maintenance,
and supplies, as much as due to its portability and dura-
bility in comparison with other imaging modalities [18].
Additionally, ultrasound is non-invasive, safe, readily
available, and widely acceptable.
Ultrasound in obstetrics and
gynecology
A typical gynecological sonographic examination includes
the following components: uterine size, shape, and orien-
tation; appearance of the endometrium, myometrium, and
cervix; assessment of the uterus and adnexa for masses,
cysts, hydrosalpinx, fluid collections, and mobility; and
evaluation of the cul-de-sac for free fluid and masses [19].
Screening for ovarian cancer with the goal of detecting
malignancy in an early stage is the greatest area of interest
of ultrasound in gynecology but did not prove beneficial in
a reduction of ovarian cancer mortality and had a high
false-positive rate [20].
Diagnostic ultrasound examinations can be used in a
variety of specific circumstances during pregnancy.
Because adverse outcomes may also arise in low-risk
pregnancies, it is assumed that routine ultrasound in all
pregnancies will enable earlier detection and improved
management of pregnancy complications. Potential life-
threatening complications and severe health outcomes
during the immediate postnatal period as a result of fetal
malpresentation, multiple gestations, ectopic pregnancy,
placenta accreta spectrum, and placenta praevia, may be
identified earlier and appropriately managed with the use of
242 Kurjak et al.: Use and misuse of ultrasound in obstetrics
an ultrasound screening study [21]. As a result of compre-
hensive health care services, ultrasound has become a
routine part of obstetric care in the developed world.
Fetal ultrasound examinations are classified as [22]:
– Standard first-trimester ultrasound assessment including
evaluation of the presence, size, location, and number of
gestational sacs with detection of a yolk sac and embryo/
fetus;
– Standard second- or third-trimester ultrasound assess-
ment – including evaluation of the number of fetuses,
cardiac activity, presentation, volume of amniotic fluid,
position of the placenta, fetal biometry, and assessment
of fetal anatomy, together with evaluation of maternal
cervix and adnexa;
– Limited ultrasound assessment – performed to answer
a specific, acute clinical question when an immediate
impact on management is anticipated and when a
standard ultrasound assessment is impractical or
unnecessary;
– Specialized ultrasound assessment – a detailed exami-
nation of women at risk for fetal abnormalities or when
fetal malformation is suspected; may include a fetal
echocardiogram, biophysical profile, and fetal Doppler
ultrasound or additional biometric measurements.
Routine ultrasound screening in
pregnancy
The American College of Obstetricians and Gynecologists
(ACOG) approved different screening modalities then
previously mentioned [23]. For a single screening exami-
nation, 18–20 weeks of gestation is the optimal time for
detection of fetal anomalies and assessment of the
placenta and umbilical cord, confirmation of singleton/
multiple gestation, and assessment of cervical length (CL),
and fetal growth [23]. If two screening exams are per-
formed, the first is typically done either at 7–10 weeks of
gestation for a reliable assessment of pregnancy dating or,
at 11–14 weeks for nuchal translucency examination,
pregnancy dating, and early depiction of fetal anatomy.
The second screening examination is performed at
18–20 weeks when fetal anatomy, growth, and pregnancy
dating are evaluated [23].
International Society of Ultrasound in Obstetrics and
Gynecology (ISUOG) recommends the first ultrasound scan
when gestational age is thought to be between 11 and
13 + 6 weeks gestation, as this provides an opportunity to
detect gross fetal abnormalities and measure the nuchal
translucency thickness [24]. In the absence of clinical
concerns, pathological symptoms, or specific indications,
routine ultrasound just to confirm an ongoing early preg-
nancy is unreasonable [24].
In its 2016 antenatal care recommendations, the World
Health Organization (WHO) recommends one ultrasound
scan before 24 weeks gestation to estimate gestational
age, improve detection of fetal anomalies and multiple
pregnancies, reduce the induction of labor for post-term
pregnancy, and improve a woman’s pregnancy experience
[25]. Once women had an early US scan, a routine scan after
24 weeks is not recommended. If an early US scan is not
performed, a scan later in pregnancy for identifying
the number of fetuses, fetal presentation, and placental
location can be considered [25].
First-trimester screening
The first-trimester ultrasound is recommended for ac-
curate pregnancy dating (ideally at 7–12 weeks) [26].
Crown–rump length (CRL) is the most commonly used
fetal measurement for this purpose [27]. Improved
determination of gestational age in early pregnancy re-
sults in fewer inductions for post-maturity [28]. If per-
formed between 11 and 14 week of gestation, ultrasound
screening should include basic fetal anatomy [26]. About
half of all major structural anomalies can be detected
in the first trimester, including acrania/anencephaly,
abdominal wall defects, holoprosencephaly, and cystic
hygroma [29].
In multiple gestations, early ultrasound allows for
reliable determination of chorionicity and amnionicity [26].
Compared with dichorionic, monochorionic twins are at
increased risk for poor perinatal outcomes such as twin-to-
twin transfusion syndrome, prematurity, fetal growth
restriction, and intrauterine fetal death. Therefore, deter-
mination of chorionicity is of great importance in the
management of multiple gestations [30].
The first trimester is an ideal time for screening for fetal
aneuploidy and the nuchal translucency (NT) measure-
ment is an excellent screening tool (Figure 1). The preva-
lence of chromosomal defects increases exponentially with
increasing NT thickness [31]. The performance of the test
can be improved even further by combining it with
biochemical markers (free-beta human chorionic gonado-
tropin – hCG and pregnancy-associated plasma protein
A – PAPP-A) and other sonographic markers such as the
nasal bone (NB), tricuspidal-valve (TCV) or ductus venosus
(DV) Doppler flow evaluation [31] (Figures 2–4).

Figure 1: Nuchal translucency (NT) in fetus with trisomy 21 at
11 weeks of gestation.
Figure 2: Absent nasal bone (NB) in fetus with trisomy 21 at
12 weeks of gestation.
Increased NT in fetuses with normal karyotype is
associated with an increased risk of fetal structural
anomalies, most commonly congenital heart defects
(CHDs) [32].
Nuchal translucency above 3.5 mm indicates possi-
bility of fetal heart defect or other malformations and
should be the reason for more detailed assessment by
maternal-fetal medicine specialist [33]. Increased nuchal
translucency in the first trimester of unknown etiology is
associated with a significantly increased risk of abortion,
fetal growth restriction, preterm birth, low birth weight,
and preeclampsia [34].
First-trimester ultrasound has been proved to be
beneficial in the detection of abnormalities in early preg-
nancy [35]. The most common conditions in the first
Kurjak et al.: Use and misuse of ultrasound in obstetrics 243
Figure 3: Tricuspid valve (TCV) regurgitation assessed by Doppler
ultrasound.
Figure 4: Ductus venosus (DV) reverse flow shown by Doppler waves
and color doppler.
trimester which can cause maternal death are severe
hemorrhage, shock, or sepsis, ectopic pregnancy, abor-
tion, and gestational trophoblastic diseases (GTDs) [35].
Ultrasound imaging is extremely useful for obtaining an
accurate diagnosis and can potentially reduce maternal
mortality rates [35].
The leading cause of maternal deaths in the first
trimester of pregnancy is ectopic pregnancy [36]. In African
developing countries, case fatality rates are 1–3% which is
10 times higher than reported in industrialized countries
[37] In Ghana and Cameroon 8.7 and 1.5% of maternal
deaths were due to ectopic pregnancy, respectively [37].
Although not recommended to diagnose pregnancy, the
first-trimester ultrasound is important in confirmation of
intrauterine pregnancy [35]. When the uterus is empty, the
244 Kurjak et al.: Use and misuse of ultrasound in obstetrics

adnexa should be thoroughly and systematically inspected Ultrasound assessment of gestational age is very ac-
[35]. The finding of an intrauterine pregnancy (IUP) almost curate in the second trimester [48]. After 14 weeks or once
always excludes the diagnosis of ectopic pregnancy (EP). the CRL exceeds 84 mm, head circumference (HC) should
However, the examiner must be aware of the possibility be used for pregnancy dating [48]. HC alone, or with femur
of heterotopic pregnancy especially if a woman has length (FL) can be used for the estimation of gestational
conceived using assisted reproductive technology [38]. age from the mid-trimester if a first-trimester scan is not
When an obvious extrauterine embryo is absent, visuali- available or the history of last menstrual period is unreli-
zation of an empty uterus, adnexal mass, free fluid, or a able [49].
pseudo sac has poor sensitivity but good specificity for Second-trimester anatomy assessment is recom-
the diagnosis of tubal pregnancy [39]. Almost 75% of all EP mended as the standard investigation for the detection of
are identified by the initial transvaginal sonography, fetal structural anomalies which are found in up to 3% of
remaining 25% are classified as pregnancy of unknown all pregnancies [29] (Figures 5–8). Congenital heart defects
location [40]. (CHD) are the most common congenital malformations and
Transvaginal sonography (TVS) provides superior causes major morbidity and mortality [29]. Prenatal
resolution and more accurate identification of the em- detection reduces morbidity and mortality by improving
bryonic structures than abdominal ultrasound, especially the neonatal condition before surgery [50].
in obese patients and ones with a retroverted uterus Placental location, its relationship with the internal
[41]. TVS enables in-vivo examination anatomy of early cervical os, and its appearance should be evaluated to
pregnancy, uteroplacental circulation, and intervillous exclude placenta previa [51]. If the lower placental edge
circulation. It is considered the gold standard in the reaches or overlaps the internal os, a follow-up examina-
diagnosis and management of incomplete miscarriage tion in the third trimester is recommended [51].
[42]. A clinical diagnosis of miscarriage, based on clinical
symptoms and vaginal examination, is inaccurate in more
than 50% of cases when compared with ultrasound
assessment [43]. Ultrasound diagnosis of miscarriage is
made on well-defined parameters which include gesta-
tional sac, crown-rump length, secondary yolk sac, and
fetal heart pulsation [43]. Additionally, to these parame-
ters, trophoblast thickness, trophoblast volume and mean
uterine artery pulsatility index are used in different
combinations in order to predict miscarriage [44].
Combining ultrasound parameters with maternal serum
markers such as human chorionic gonadotrophin,
progesterone, PAPP-A, and high-sensitivity C-reactive
protein, are used to determine the eligibility of expectant Figure 5: Atrial septal defect type secundum.
management of missed miscarriage [45]. Up to 70% of
women will choose expectant management of miscarriage
if given the choice [46]. This could significantly reduce the
number of unnecessary evacuations of the retained
products of conception [46].

Second-trimester screening

The second trimester ultrasound assessment is performed

between 18 and 22 weeks of gestation which is the best time
for a fetal depiction of fetal anatomy and detection of
congenital malformations if present [47]. Ultrasound
screening includes evaluation of the number of fetuses,
gestational age, anatomy of the fetus, placenta, maternal
uterus, cervix, and adnexa [47]. Figure 6: Ventricular septal defect.

Figure 7: Omphalocele.
Figure 8: Occipital encephalocele.
A low-lying placenta sonographically diagnosed in
the second trimester typically resolves by the mid-third
trimester [52]. Only 9.8% of previas and low-lying
placentas persist through delivery [53]. Women with
a history of uterine surgery and low anterior placenta
or placenta previa should be examined for findings of
accreta, and if accreta is suspected, a more detailed
evaluation is usually required to further investigate this
possibility [51] (Figure 9).
Fetal biometry alone showed poor to moderate per-
formance in prediction of small for gestational age (SGA)
[54]. When combined with uterine artery Doppler, detec-
tion of term, preterm and very preterm SGA is 40, 66 and
89% respectively [54]. Uterine artery pulsatility index alone
was able to predict 25, 60 and 77% of term, preterm and
very preterm SGA at a 10% false-positive rate [54].
Kurjak et al.: Use and misuse of ultrasound in obstetrics 245
Figure 9: 3D color Doppler assessment of placenta previa.
Routine Doppler ultrasound is not currently recom-
mended as part of second-trimester screening in low risk or
unselected pregnancies as it confer no benefit on mother
or baby [55]. However, Doppler studies are important in
prediction of high-risk pregnancies and their outcomes.
Use of Doppler ultrasound on the umbilical artery in high‐
risk pregnancies reduces the risk of perinatal deaths and
may result in fewer obstetric interventions [56]. Elevated
second-trimester uterine Doppler indices, as the indicator
of impaired placentation, are more strongly associated
with stillbirth than conventional risk factors [57]. Both
uterine and umbilical artery Doppler are used for the
prediction of preeclampsia and fetal growth restriction
(FGR) to reduce the maternal and perinatal morbidity and
mortality [58].
Preeclampsia is among the leading causes of maternal
and fetal/neonatal mortality and morbidity with incidence
of 2–7% of all pregnancies in developed countries and
approximately 10% in developing countries [59]. Early
identification of pregnant women at risk for preeclampsia
is important to implement preventive measures and timely
treatment. Some biochemical and ultrasonographic pa-
rameters have shown promising predictive value both in
the first and second trimesters [60]. Uterine artery Doppler
ultrasonography (Pulsatility Index) is better in predicting
the occurrence of preeclampsia in the second trimester
than in the first trimester [61]. The risk of severe pre-
eclampsia was best predicted by second-trimester elevated
resistance index [62]. The diastolic notch in uterine arteries
in the second trimester of pregnancy is designated as an
independent predictor of preeclampsia, especially when
present bilaterally, with a positive and negative predictive
value of 90.91 and 42.11%, respectively [63].
A short CL (≤25 mm) on transvaginal ultrasound
between 16 and 24 weeks of gestation is associated with an
246 Kurjak et al.: Use and misuse of ultrasound in obstetrics

increased risk for spontaneous preterm birth [64]. Besides

being more cost-effective, a single CL measurement at
18–24 weeks of gestation showed to be a better predictor of
preterm birth than changes in CL over time [65]. Moreover,
the short cervix is more sensitive for predicting earlier
forms of prematurity (at <32 weeks) than later forms of
prematurity (>32 weeks) [66]. Prematurity has been the
leading worldwide cause of neonatal mortality but also the
leading cause of childhood mortality through the age of
five years [67]. In 2005, 12.9 million births, or 9.6% of all
births worldwide, were preterm [68]. Approximately 11
million (85%) of these preterm births were concentrated in
Africa and Asia [68]. Routine transvaginal measurement of
CL as a strategy for preventing premature birth is still
controversial [69]. Large randomized controlled trials have
failed to demonstrate proven efficacy for universal CL Figure 10: Severe FGR with absent end-diastolic flow in the umbil-
screening and cerclage placement in women with short CL ical artery.
because a large number of women need to be screened to
prevent a relatively small number of preterm births [69]. On
of over 50% [78]. The predictive performance of routine
the other hand, limiting CL screening to women at risk
third-trimester ultrasound for LGA is higher when the scan
results in missing nearly 40% of women with a short cervix
is performed at 36 than at 32 weeks [77]. Patients at high
[70]. Rates of early but not late spontaneous preterm birth
risk for fetal growth restriction often have two third-
are significantly higher among women who do not undergo
trimester screening examinations, one at 32 weeks and the
CL screening [71]. In patients with a short cervix, treatment
other at 36 weeks [24]. Identification of fetuses at risk for
with vaginal progesterone or, in cases of previous preterm
FGR will allow timely management that can reduce peri-
birth, cerclage have reduced the rate of subsequent
natal morbidity and mortality [76]. Severe FGR is consid-
preterm birth and composite perinatal mortality and
ered when absent end-diastolic flow is present in umbilical
mortality [72].
artery, as shown in the Figure 10.

Third-trimester screening
Screening examinations in the third trimester are
pregnancy-specific, its routine use in low pregnancies is
not supported [73]. A routine ultrasound during the third
trimester is used for the evaluation of fetal growth and
presentation, amniotic fluid, and placental growth
and location but also for a second evaluation of fetal
morphology [74]. Incidental fetal anomaly is found in
about 1 in 300 women scanned in the third trimester [75].
Third-trimester ultrasound is of great importance in the
screening for late-onset preeclampsia, evaluation of
uterine scar in a women with a previous cesarean section,
prediction of labor, and management of fetal malpre-
sentation and large for gestational age fetuses (LGA) [76].
LGA, i.e. macrosomic neonates (birth weight > 90th
percentile) are at increased risk of perinatal death, birth
injury due to traumatic delivery, and adverse neonatal
outcomes [77, 78]. Two common ultrasound markers for
macrosomic neonates at birth are estimated fetal weight
(EFW) and abdominal circumference (AC) with a sensitivity
Ultrasound in developing countries
The World Health Organization (WHO) estimated in 1997
that 50% of developing countries had no access to ultra-
sound imaging, and available equipment was outdated or
broken [79]. Portable ultrasound machines have become
increasingly popular in LMICs (Low and Middle Income
Countries) due to their affordability, simplicity, and effec-
tiveness for patient management decisions in resource-
poor settings [80, 81]. Small portable ultrasound device for
use in LMICs is presented in the Figure 11.
According to Immelt, such pocket-sized technology
like Vscan (Figure 11) has the potential to help redefine the
physical exam and improve patient care by enhancing a
doctor’s ability to quickly and accurately make a diagnosis
[82].
A recent study identified the overall trend of increased
training programs and ultrasound applications in LMICs
over the past decade, primarily for obstetrical use and
screening [81]. Studies in Cameroon and Liberia showed

Figure 11: Smart phone-sized ultrasound system Vscan (GE
Healthcare, Chicago, Illinois, United States).
that 48 and 53% of ultrasound scans, respectively, were
performed for either obstetric or gynecological conditions
[83]. An antenatal ultrasound program as basic screening
for high-risk pregnancies introduced in 2010 at a commu-
nity health care center in rural Uganda resulted in a sig-
nificant increase in the number of deliveries in a health
facility and antenatal care visits [84].
The vast majority of all maternal and newborn deaths
occur in developing countries [5–7]. As approximately 40%
of fetal, neonatal, and maternal deaths occur during
the peripartum period, early diagnosis of risk factors
for intrapartum-related complications and subsequent
referrals are the key strategic research priorities for devel-
oping countries [3]. In many developing countries, a baby
born at 32 weeks of gestation (in the absence of intrauterine
growth retardation) has little chance of survival, while the
survival rate of infants born at 32 weeks in developed
countries is similar to that of infants born at term [85]. An
infant born at 32 weeks in a low-income country has only a
50% chance of survival [86].
There is evidence that obstetric uses of ultrasound
improve patient management, but evidence of reducing
maternal, perinatal, or neonatal mortality is opposing [87].
A study on 58 clusters across 5 LMICs (DRC, Kenya, Zambia,
Gvatemala and Pakistan) compared usual care and inter-
vention that included basic ultrasound at 16–22 and
32–36 weeks with referrals for US-diagnosed conditions
[87]. There was no difference in intervention and compar-
ison clusters in terms of antenatal care use, facility de-
livery, stillbirth rate, neonatal mortality, and maternal
Kurjak et al.: Use and misuse of ultrasound in obstetrics 247
mortality despite US-naïve providers being successfully
trained to conduct basic US exams [87]. Studies conducted
in South Africa showed that routine second-trimester
ultrasound scanning is not associated with substantive
improvements in maternal or fetal outcomes [21].
Other trials proved that the use of ultrasound in
obstetrics improves patient management in the developing
world particularly through assessment of a number of
gestations, fetal presentation, placental position, esti-
mated due date and fetal growth [88]. In skilled hands,
prenatal ultrasound showed the potential to reduce
maternal, fetal, and neonatal mortality by improving the
management of pregnancy complications and reducing
birthing complications due to more deliveries in risk-
appropriate settings [89]. With appropriate ultrasound
machines, essential supplies, and capacitating mid-level
providers, a significant number of high-risk pregnant
women can be identified on time and managed or referred
to health facilities with safe delivery services [90].
A study conducted in 25 health centers in Ethiopia
estimated the contribution of obstetric ultrasound services
to the prevention of maternal and neonatal morbidities and
mortalities [90]. The investigators considered all possible
risks for maternal and neonatal morbidities and mortalities
which can be reduced through confirmation using
advanced perinatal health services accessed through
referral linkage [90]. The ultrasound service has contrib-
uted to the prevention of 1,970 maternal and 19.05 neonatal
morbidities and mortalities per 100,000 and 1,000 live
births respectively during the assessed two-year period
[90].
Education
The education of health personnel is an important factor in
obstetric ultrasound services’ quality implementation. An
ultrasound machine alone won’t achieve benefits without
properly trained health workers. A review article, that
documented training opportunities for ultrasonography in
LMICs, showed that most ultrasound scans are performed
by general practitioners, obstetric physicians, and even
non-medical personnel with little to no formal training
in ultrasonography [91]. Additionally, ultrasonographic
training in LMICs often does not meet the WHO criteria
such as the number of scans under the supervision and the
length of the training program [91].
With adequate training materials and methods, short
intensive training courses provide substantial acquisition
of knowledge and practical skills [83]. One study showed
that after a 2-week course in basic obstetrics ultrasound
248 Kurjak et al.: Use and misuse of ultrasound in obstetrics
and a 12-week period of oversight, trainees with no prior
ultrasound experience performed basic OB ultrasound
examinations independently to screen for high-risk preg-
nancies and achieved a 99.4% concordance in ultrasound
diagnosis with reviewers [92].
Misuse of ultrasound
Unfortunately, besides all the exceptional benefits of
ultrasound in obstetrics, its inappropriate use and abuse
are reported. Obstetric ultrasound practice is ethically
justifiable only if the indication for its use is based on
medical evidence [93]. Using ultrasound to view, take a
picture, or determine the sex of a fetus without a medical
indication can be considered ethically unjustifiable [93].
A study in Botswana reported unindicated overuse of
ultrasound by health professionals and neglect regarding
conventional methods such as physical examinations and
taking histories because of easy access to ultrasound [83].
A study conducted in Uganda reported overuse of ultra-
sound which was not associated with any identifiable
effect on obstetric outcomes [94].
Financial motivations in providing unnecessary
ultrasound services have been reported as way of misuse in
LMICs [83]. After the initial ultrasound scan, multiple
follow-up scans are often scheduled in private clinics to
increase revenue [83]. Using ultrasound for financial gain
or any not clinically-based reason significantly reduces the
cost-effectiveness of services [83].
In some parts of the world, most notably in Asia,
existing cultural biases have led to the inappropriate use
of ultrasound scanners in sex selection by abortion if the
baby is not of the desired gender [95]. In China, where son
preference is aggravated by the historical One-Child Policy,
Figure 12: Female (left) and male (right) gender at 12/13 weeks of gestation.
and in India, where female infanticide is replaced by
sex-selective termination of pregnancy (TOP), prenatal sex
determination is banned [95]. Still, it remains a widespread
practice and sex-selective TOP have a number of negative
demographic effects [96]. In one study in Nepal, approxi-
mately 7% of women sought an ultrasound examination for
fetal sex determination, predominantly ones with three or
more live-born daughters and no live-born sons, which
could indicate the intention of sex-selective abortion [97].
Ghanaian study about women’s experience and perception
of ultrasound in antenatal care documented knowing
fetal sex as a major motivation for which women go for
antenatal scans [98]. However, fetal sex was accurately
determined in only 86.5% of the cases [98]. Incorrect
assessment of the fetal sex is not uncommon and can result
in negative experiences for women, especially in cases
when female fetuses are mistaken as male [83]. Accurate
determination of fetal sex by ultrasound is shown in the
Figure 12.
Conclusions
There is clear evidence of the importance of ultrasound in
preserving feto-maternal health. The use of ultrasound in
diagnostics is essential for the patients, the doctors, the
healthcare system and for the entire society. Ultrasound
assessment when indicated should be every woman’s right
in the new era. However, it is still only a privilege in
some parts of the world. Investment in both equipment
and human resources has been clearly shown to be
cost-effective and should be an obligatory step in the
improvement of health care. Well-developed health
systems should guide developing countries, creating
principles for the organization of the health system with an

accent on the correct, legal, and ethical use of diagnostic
ultrasound in pregnancy to avoid its misuse.
Research funding: None declared.
Author contributions: All authors have accepted respon-
sibility for the entire content of this manuscript and
approved its submission.
Competing interests: Authors state no conflict of interest.
Informed consent: Not applicable.
Ethical approval: Not applicable.
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